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C-57 Licensed Water Well Contractor Date Signed License Number <br /> i4v .,<q"4x� k h�F,..l r'^3"y ti'}fty�'!C�' �,d � a• ''Y"t4 y, <br /> 111M, M.M., �fi� -y'`yif��� 5+ � faf� ae. <br /> �., A4. n.c.- �'. _.. _y?r e :.ia.z• .n ..i.,.,_ + <br /> CSG# State Well Number Site Code Local Well Number <br /> ---- ---- ---- N ---- ---- ---- W <br /> Latitude Deg/Min/Sec Longitude Deg/Min/Sec <br /> APN: -- <br /> Township: Range: _ <br /> Section: Tract: _ <br /> SEQ: BM: _ <br /> No Attachments <br /> DWR Form 188 rev 10/09/2025 Page 3 of 3 <br />